POLICY: In order to complete the certification, each WIC applicant/participant is required to have their hemoglobin tested according to the procedures listed below to identify individuals at risk of becoming anemic, to assure appropriate WIC Program benefits for those in greatest need, and to protect the safety of applicants/participants and WIC personnel performing the tests. The value must be collected in clinic or provided by a healthcare provider at the certification appointment. PROCEDURE: A. Categorical Hematological Testing 1. Infants: a. Under nine (9) months of age at the time of initial certification and follow-up visit are not required to have a hematological test performed. b. Blood work must be collected on infants between nine (9) months of age and prior to thirteen (13) months of age. 2. Children: a. Children between 1 and 2 years of age must have at least (1) hematological test performed, preferably 6 months after the infant screening. b. Children between 2 and 5 years of age with a normal hemoglobin value are required to have a hematological test once every 12 months. 3. Pregnant women must have a hematological test performed during the pregnancy certification. 4. Breastfeeding women must have a hematological test performed when they are initially certified as breastfeeding. a. If a hematological test is performed when a woman is initially certified as breastfeeding, and then breastfeeding is discontinued, a hematological test does not have to be performed when there is a category change to non-breastfeeding postpartum. 5. Postpartum non-breastfeeding women must have a hematological test performed at the time they are certified under that category. 1 of 6
B. Collection of a Hematological Value 1. The WIC Staff will use a single use lancet that is completely disposable. No spring loaded lancet devices are to be used in clinic sites to obtain blood samples for hemoglobin measurements. 2. A participant who is not cooperative during an appointment in which hematological testing is required to be rescheduled. 3. Hemoglobin testing is required to complete the certification. The value must be collected in the clinic or provided by a healthcare provider at the certification appointment. a. Referral documentation from a healthcare provider will be accepted on the following: 1. Official medical records 2. Prescription pad 3. Healthcare provider s letterhead b. Referral documentation must: 1. Be reflective of a woman applicant s category 2. Conform to anemia screening schedule for infants and children 3. Be documented in Crossroads with the date the blood test was conducted 4. Hematological values will be documented in the Crossroads Anthro/Lab screen. 5. Hematological measurements are taken in grams per deciliter (g/dl). All clinic staff must complete a Source of Measurement form (Attachment #1) to acknowledge their understanding of how blood will be measured. Signed copies of Attachment #1 will be kept on site for each Local Agency. C. Referral and Follow-up of High Risk Hemoglobin Values The Competent Professional Authority (CPA) must make an immediate referral to the participant s health care provider when a hemoglobin value generates a high risk status. 1. The referral will be documented by the CPA in Crossroads. 2. Repeat the test in ninety (90) days if there is no evidence of a course of treatment (i.e. physician testing results, observation of iron prescription). 2 of 6
3. A repeated test is not required when the health care provider documents an improved hemoglobin value and/or a course of treatment following the referral. The improved value and/or course of treatment will be documented by the Nutritionist CPA in the Crossroads Care Plan. 4. Nutrition education will be provided by the CPA and the initial and follow-up contacts will be documented by the CPA in the Crossroads Care Plan. D. Referral and Follow-up of Abnormal Hemoglobin Values Repeat the test in ninety (90) days for a participant with a low hemoglobin value that does not generate a high risk status. Nutrition education will be provided by the CPA. 1. Postpartum women, both breastfeeding and non-breastfeeding, will not require a follow-up unless their blood value is less than or equal to 10.0. 2. When the second hemoglobin value is lower than or equal to the first, the CPA will make a referral to the participant s health care provider. a) The CPA will document the referral in Crossroads. b) Repeat the test in ninety (90) days if there is no evidence of a course of treatment (i.e. physician testing results, observation of iron prescription). 3. When the second value is higher than the first, though continues to be below normal, repeat the test in ninety (90) days. 4. When the second value is in the normal range, do not repeat the test in ninety (90) days. 5. The initial or follow-up contact is not required to be documented by the CPA in the Crossroads Care Plan when hemoglobin value does not give the participant a high risk code. E. When Hematological Testing is Not Required 1. Hematological testing is not required when religious beliefs will not allow applicant/participant to have blood drawn. a) A statement of the refusal to have blood drawn will be scanned into the participant s chart. 3 of 6
b) The applicant/participant may be certified based on other identified risk criteria. 2. Hematological testing is not required when an applicant/participant has a medical condition such as hemophilia, fragile bones (osteogenesis imperfecta), sickle cell anemia, thalassemia or a serious skin disease in which the testing procedure could cause harm to the applicant/participant. a) Documentation from a physician of the medical condition and specifying whether it is short term or life long will be scanned into the participant s chart. b) If the condition is considered to be treatable, a new statement from the physician is required during each subsequent certification. c) If the condition is considered "life long", a new statement from the physician is not necessary for subsequent certifications. d) An effort should be made to obtain hematological values (if they exist) from the applicant's/participant's health care provider. 3. Crossroads will allow the bypass of the hematological testing when one of the above conditions exists. a) Crossroads will not assign any risk codes related to anemia. b) The CPA will not be able to manually assign risk codes. c) The reason for bypassing the hematological testing will be documented by the CPA in the Crossroads Care Plan. F. Persons Infected with Human Immunodeficiency Virus (HIV) 1. Persons infected with human immunodeficiency virus (HIV) must have hematological testing for WIC certification performed on site if it is the normal operating procedure of the WIC clinic to perform hematological testing on site. 2. If it is determined that the health and safety of WIC personnel is severely at risk, other means would be justified in providing the service. Example: If the applicant/ participant is known to be HIV-infected and is hostile and physically abusive, they could be referred to another location to have blood drawn. 4 of 6
a) There will be no cost to the applicant/participant for the testing. b) The situation will be documented by the CPA in the Crossroads Care Plan. G. Training 1. Initial training of each WIC personnel performing hemoglobin testing will be conducted at the State Agency during Crossroads training within six (6) months of employment. Training may be conducted by the Local Agency with use of the Hematology - A Training and Reference Manual for Clinics, 1997 when the WIC personnel must perform the task of hemoglobin testing prior to their attending training at the State Agency. 2. Annual training of each WIC personnel performing hemoglobin testing will be conducted by: a. A person assigned by the State Agency during the biennial State WIC Meeting; or b. A person assigned by the Local Agency Director to be performed at the Local Agency. 3. Training will include the following: a. HemoCue Machine Procedure; b. Maintenance and Calibration, and c. Problem Prevention. 4. Training will be documented on the Training and Continuing Education Activities sheet and a copy placed in the In-service File (see Policy 1.19, Training Policy). H. Quality Control and Calibration of HemoCue Machines Upon notification, each Local Agency s Hemocue Machines will be cleaned and/or calibrated at State WIC Meetings. I. Hematology Training and Reference Manual Refer to the Hematology - A Training and Reference Manual for Clinics for complete protocol for hematological testing. 5 of 6
REFERENCES: 1. WIC Regulations 264.7, Determination of Nutritional Risk 2. SFP 91-032, Implementation of WIC Minimum Data Set 3. SFP 01-041, WIC Final Policy Memorandum, WIC Bloodwork Requirements 4. SFP 09-046 WIC Hematological Data Requirements: Clarification 5. Hematology - A Training an Reference Manual for Clinics, 2001 6 of 6